Moral Injury: “A Profound Sense of Alienation and Abject Shame”

After more than a decade of war, post-traumatic stress disorder – PTSD — is unfortunately a too-familiar term. It is recognized in the Diagnostic and Statistical Manual (DSM) of mental disorders – the Bible of mental-health providers — and its definition has been updated recently.

The term “moral injury” is less well-known (amazingly, it even lacks a Wikipediaentry, although it has surfaced on Battleland, including here and here).Moral injury is also commonly associated as a consequence of war. It is related to PTSD, but is not a defined medical condition.

Although discussed and defined by psychiatrists including Brett Litz,Bill Nash and Jonathan Shay, it is not yet part of the common lexicon of therapists, or the general public.

I am writing about it because I think that it is an important concept to help understand the experiences of our service members.

Moral injury arises when a service member cannot reconcile what he has done, or experienced, in war with his worldview of him or herself prior to war. Commonly this involves killing, especially when the slain are non-combatants, often women or children.

Especially troubling to the psyche is when the service member enjoyed the act of killing. Commonly secrecy and shame accompany an internal conflict. War crimes may also give rise to a corrosive seepage into the soul.

Why is the distinction between PTSD and this so-called moral injury important?

More and more, therapists are finding that these psychological injuries of war must be treated differently. Medications and exposure therapy, the gold standards for treatment of PTSD, do not work by themselves for shame and guilt.

What does work?

We do not yet know. What I hear from my therapist colleagues is about letting the service member tell their story in a way and in a place that they will not be judged. This may be with other combat-hardened veterans, or with a chaplain or therapist that they trust.

One of these therapists, Michael Castellana from the Oasis program in San Diego, wrote in an e-mail:

…what we are calling “moral injury” (moral exile serves to describe not only the initial “injury” but the process that ensues afterward), has everything to do with the darkness that warriors enter into, which altogether changes the context and belief systems that surround that warrior at some point afterward. Simply stated: It is the unspeakable part of war and is so utterly repugnant to most people, that it is pushed so far out of awareness, leaving the men and women I work with (and others as well, most likely) alone.

Innumerable times in my career, Marines have uttered the phrase – “we’ve never talked about it”, or “I have never told anyone this, not even the guy who was with me”…It causes such a profound sense of alienation and abject shame that our service members feel and believe about themselves that, in spite of themselves it seems, they are lost to the rest of time and forever exiled from any sense of community for their actions/inactions.

I am humbled by the lengths to which humans will go to survive, including taking part in a membership in combat; in a contract that they haven’t had the time to read all the fine print before signing, that will forever afterward condemn them to what they oftentimes find as a barren, forlorn and unforgiving existence. It is no wonder that suicide is so highly correlated with this thing we call “moral injury.”It’s why I do this work. In its purest sense, we are saving lives, by being willing to listen to them without condemning them and bear witness to their truth; to help to shed some precious light, and a warm, compassionate hand out of their darkness.

As many of our returning Soldiers and Marines struggle to make sense of their repeated exposure to—and participation in—carnage and death, we need to be able to have therapists and chaplains and police officers and judges who can help them through such dark places.